WAC 388-475-0050   SSI-related medical -- General information.  (1) The department provides medical benefits under the categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:

     (a) Age sixty-five or older;

     (b) Blind with:

     (i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

     (ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.

     (c) Disabled:

     (i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:

     (A) Can be expected to result in death; or

     (B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

     (C) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.

     (ii) Decisions on SSI-related disability are subject to the authority of:

     (A) Federal statutes and regulations codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended; and

     (B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.

     (2) A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the department unless the applicant's:

     (a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or

     (b) Medical condition has changed since the SSA denial was issued.

     (3) The department considers a client who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a client is eligible for CN medical coverage under WAC 388-474-0005.

     (4) Individuals referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:

     (a) For all programs:

     (i) WAC 388-408-0055, Medical assistance units;

     (ii) WAC 388-416-0015, Categorically needy and WAC 388-416-0020, Medically needy certification periods;

     (iii) Program specific requirements in chapter 388-475 WAC;

     (iv) WAC 388-490-0005, Verification;

     (v) WAC 388-503-0505, General eligibility requirements for medical programs;

     (vi) WAC 388-505-0540, Assignment of rights and cooperation;

     (vii) Chapter 388-561 WAC, Trusts, annuities and life estates.

     (b) For LTC programs:

     (i) Chapter 388-513 WAC, Long-term care services

     (ii) Chapter 388-515 WAC, Waiver services.

     (c) For MN, chapter 388-519 WAC, Spenddown;

     (d) For HWD, program specific requirements in chapter 388-475 WAC.

     (5) Aliens who qualify for medicaid benefits, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 388-438-0110.

     (6) The department pays for a client's medical care outside of Washington according to WAC 388-501-0180.

     (7) The department follows income and resource methodologies of the Supplemental Security Income (SSI) program defined in federal law when determining eligibility for SSI-related medical or Medicare Cost Savings programs unless the department adopts rules that are less restrictive than those of the SSI program.

     (8) Refer to WAC 388-418-0025 for effects of changes on medical assistance for redetermination of eligibility.



[Statutory Authority: RCW 74.04.050, 74.08.090. 04-09-002, § 388-475-0050, filed 4/7/04, effective 6/1/04.]